The crisis of American medicine is not tobacco, AIDS, silicone implants, the Gulf War Syndrome, breast or other forms of cancer, physician-assisted suicide, euthanasia, licensure, medical care for the poor, or any other specific medical or ethical issue. The crisis of American medicine is far greater than any one of these problems, indeed it is far greater than all of them combined, because the answers to these problems do not come from within them but from medical ethics. It is the same crisis that faces our culture in every other area, how do we decide ethics? That is, how do we decide what is right and what is wrong? Is there a method which will stand the test of time or do ethics change with changing cultures? How are medical-ethical decisions decided today?

Few Are Consistent

What is needed is a standard or a method whereby to determine ethical decisions. Since the Hippocratic Oath is our focus today, I will start there. The Hippocratic Oath has had an amazing longevity, if not an impact over medicine for more than two millennia. However, in recent times, many ethicists pick and choose from it, rather than endorse the whole. Occasionally, I read an ethical opinion that appeals to the Hippocratic Oath. For example, there might be an appeal for the responsibility of students to their teachers or physicians not taking advantage of the sick in their vulnerable circumstances.

However, I know that those writers would never embrace the Oath's prohibition against abortion or euthanasia. So the Oath is really no standard at all when one has a freedom to pick and choose what one does or does not like about it.

Many, if not most, people would argue for the democratic approach. Indeed, this may be the major direction of American medicine. Consensus panels are determining treatment for every problem from otitis media to myocardial infarctions to lung cancer. Standards are set by experts.

However, there is not a person in this room or anywhere else that will not disagree with more than one of these consensus statements, whether they concern medical treatment or medical ethics. Obviously, there is some other standard that we are following when we stand as an individual against "consensus."

Or, there is the approach that might makes right. Few people would openly choose this method, especially using these exact words. However, we all are quite willing to use authority when we think it right. Recently, one physician called on state licensure committees to take away the licenses of any physician who attempted to help a homosexual change his sexual orientation.

Pro-abortionists went after the Supreme Court to make their position law, and now pro-life people want the law changed. While we shy away from the label, "Might makes right," we are quite willing to use it to promote what we believe.

Many today argue for pluralism. Pluralism also has other names: multi-culturalism and cultural diversity. Pluralism sounds loving. It sounds accepting of every opinion and approach. However, in practice, pluralism is not practical and those who advocate it are dishonest.

Pluralism is impractical because it cannot decide a course of action. Pluralism cannot decide the abortion issue. If you and I disagree about abortion, both our ideas cannot be implemented. That is indeed why abortion continues to be a dividing force in the United States. Pluralism on a serious issue does not work. Neither side is willing to give up their position, and, each should not.

Most who advocate pluralism only advocate those positions with which they agree. For example, those who are "pro-choice" on abortion are often accepting of homosexuals, radical environmentalists, and advocates of gun control, but will vigorously deny even the right of Christian fundamentalists to speak.

Note the words of one who wrote against my article in the Medical Sentinel: "Fundamentalism is moral arrogance and moral imperialism whether in Afghanistan, Iran, or the Christian Right in the U.S.A." May I ask, simply, why my opinion is "moral arrogance and imperialism" and his is not? The worst totalitarian regimes of the 20th Century were profoundly and consistently atheistic, not religiously fundamentalistic. If we are a pluralistic society, why is my opinion condemned and his is not?

It may startle you from what I have just said to say that I think that true pluralism would be a start in the right direction. When, however, have you seen a condemnation of evolution, abortion, or homosexuality in The New England Journal of Medicine or JAMA or any medical publication? Our medical journals are not pluralistic, they are decidedly and consciously pro-abortion, anti-Christian, and anti-other issues. They are narrowly close-minded while advocating pluralism. Any opinion on medical-ethical issues is permitted as long as it is not fundamental religion. That, my colleagues, is dishonest!

A blinded reviewer of my article for the Medical Sentinel wrote: "AAPS does not pretend that religious beliefs are irrelevant, as anyone who reads our publications carefully or attends the annual meeting can attest. The people who are hostile to religion certainly get the message, and they do not hesitate to tell us that they are offended. But, it is not our purpose to preach. We accept certain principles and live by them.... The MedicalSentinel is a medical journal, not a religious tract."

Is he correct that the Medical Sentinel, indeed, any medical journal is "not a religious tract?" Let me expand my question, "Can medicine be practiced apart from one's religious beliefs?"

The Practice of Medicine Is Inherently Religious

I would contend that the practice of medicine is inherently and inescapably religious. I would also contend that medicine's failure to recognize and apply this connection has caused more morbidity and mortality than it has alleviated.

Let me see if I can back up this profound statement.

First, medicine has failed to endorse the marriage of a man and a woman for life as the most healthy pattern. My own organization, the American Academy of Family Physicians (AAFP), destroys its own raison d'être by accepting whatever couples or groups of people decide to live under the same roof or associate together.

Yet, scientifically, marriage of a man and woman are far and away the most healthy situation. Shouldn't we as physicians be interested in the health of our patients and the American population?

· In a recent report from the CDC, 87 percent of reportable diseases were sexually transmitted. Sexual abstinence before and fidelity in marriage prevent all sexually transmitted diseases.

· Hundreds of studies show that children from broken homes have more medical problems, cause more social disruption and even criminal activity, and are poorer achievers. Yet, over and over from so-called medical authorities, I have heard the "Ozzie and Harriet" families made fun of and unnatural marriages of homosexuals endorsed.

· Homosexuality promotes a morbid and deadly existence. Homosexuals have a high prevalence of STDs and other diseases, psychiatric problems, violence, and criminal activity. However, as I mentioned above, in major medical publications so-called experts have called for the de-licensure of any physician who advocates or helps a homosexual to change his lifestyle.

With its endorsement of homosexuality in 1973, the medical profession opened the way for the AIDS epidemic. I would not go so far as to say that the AIDS epidemic would never have happened without that endorsement, but certainly the epidemic was enhanced by that decision.

· In 1977, Dr. James Lynch wrote a book, The Broken Heart, which demonstrated that married couples had better health and longevity in a wide variety of disease and psychological problems than single people.

Second, medicine has failed to condemn abortion. Abortion wreaks havoc on life expectancy. If life expectancy is considered to be 75 years, and abortion deaths are factored in, life expectancy becomes about 43 years (2 million natural deaths and 1.5 million abortions).

Third, medicine has essentially left religion out of psychiatry. Answers to family and social problems are sought in a pill, rather than religion which is often the only answer to their problems. I do not deny real organic psychiatric problems, but millions of Americans are needlessly medicated with the serious side effects and morbidity and mortality that those medications cause, while having their real situational problems camouflaged.

Fourth, medicine has been an accomplice to increasing crime. The evolutionary view of man cannot accept that some people are just mean and evil. Thus, anyone and everyone has the potential for "rehabilitation." Yet, repeated studies show that psychiatrists are no better predictors of behavior than flipping a coin.

The point I want to make here is that medicine is inherently religious because health, disease, and injury have a great deal to do with behavior. Should our medical journals become "religious tracts?" Should physicians "preach?"

No, our medical journals should not become religious tracts, but there ought to be open and honest debate about behavioral issues that are religious with medical consequences. Apart from purely religious journals, that debate is not allowed today. And, as I have pointed out, ill health and poor medicine have been a result.

Please understand, I am not advocating any more that what our medical leaders and editors purportedly advocate, that is, the open and honest debate allowed by true pluralism. That openness must necessarily include discussions of religion.

Conclusions

Medical ethics is in a state of chaos today: "Everyone does or advocates what is right in his own eyes." While science may help us figure out how to help our patients medically, it cannot tell us what is right and wrong. What can? Public opinion? The force of law? Expert panels? Consensus of the AMA or AAPS?

I don't think any one of us would find the ethical guidance we require of ourselves or our patients from any one group or even a variety of groups. How, then, do we decide?

For medicine to become the potent force for healing of which it is capable with modern technology, it must return to some older ways --- those of religion. Only people with extreme biases can ignore that the United States was forged in the crucible of religion, specifically Christianity. Our weakness has come as we have denied God and denied our roots in Him and His Word.

Yes, I think that substantial portions of our medical journals should carry religious debate over both ethical and medical issues. Science has shown that marriage is healthy, but God told us that several thousand years ago. God told us that "all things in moderation" are healthy, long before the dietary confirmation of modern science. God told us that exercise was healthy, but spiritual health was more important to true health.

If anyone is disturbed by this direction, and I suspect that more than one here today is, let me state that religious opinion is unavoidable. Absolutes are unavoidable. For example, "There are no absolutes" is an absolute statement that contradicts itself. Or, "Everything is relative," another absolute that contradicts itself. If, then, there are absolutes, where do we find them? Not in science which is conditioned by the particulars of its design; not in the vagaries of politics, public opinion, so-called "experts," etc.

Absolutes are found in religion. For example, the Ten Commandments are not 10 suggestions!

I challenge the AMA, the AAPS, the AAFP, and other medical organizations to return us to our God and to our roots for the health of our patients and our nation!

Dr. Payne is an Associate Professor of Family Medicine at the Medical College of Georgia. His address is Department of Family Medicine, Medical College of Georgia, Augusta, GA 30912-3500.